“To be or not to be, that is the question,” is the famous line from the play Hamlet. For many doctors, especially pain management physicians, they battle with a similar question with every patient they encounter – “To prescribe or not to prescribe.”

Medication prescription and the written and unwritten rules that govern the practice have been a hot button issue of late, especially during the pandemic. In an effort to stay up to date on the latest news regarding chronic pain care, we often find stories blasting doctors for over-prescribing or doctors who find it necessary to validate their very real and very appropriate treatment plan that involves the prescription of opioids. Patients are also caught in the mix. Heck, I’ve had a colleague killed by a former patient because they would not prescribe opioids, which only makes it harder for patients with legitimate ailments and conditions that can effectively be managed by opioids to get their hands on the medications they so desperately need.

The debate over opioids has in some ways mirrored the most recent presidential election. Any reasonable person realizes that neither party is right 100 percent of the time, but many of the loudest Republicans and loudest Democrats only seek to champion their beliefs and refuse to listen to what the other side has to offer. We’ve seen the same situation play out with opioids, as it seems like we’re either hearing about opioid hysteria and mass over-prescribing or that no doctor should ever stand in the way of a patient who wants painkillers for their pain condition. And just like with politics, the answer tends to lie somewhere in the middle.

Prescribing Or Not Prescribing

There is no one-size-fits-all answer to whether or not a physician should always or never prescribe opioids, because every individual and every pain condition is unique. Even in patients who have similar characteristics and similar pain conditions, it’s irresponsible to say that they should always or never receive opioids as part of their care plan. An assessment needs to be made on an individual basis and it needs to be made on the totality of the situation.

There are so many different factors that need to be understood before a doctor makes a determination as to whether or not painkillers would be in the patient’s best interest. There are the obvious factors like age and diagnosis, but there are also the less-than-obvious factors like whether or not underlying anxiety or a mental health condition could be exacerbated by beginning a new opioid regimen. A physician will also dive into a patient’s medical and family history to look for signs of abuse or potential abuse. It’s not that the doctor doesn’t trust the patient with opioids, it’s that we want to make sure we’ve uncovered all potential hurdles to successful treatment. Navigating known potential obstacles is so much easier than trying to blindly push forward with a care plan.

And of course, a good pain physician will listen to the patient. We want to learn about your goals, your wishes and your concerns and factor those into our decision to prescribe opioids. During our decades of practicing medicine, we’ve certainly encountered the patient that clearly has ulterior motives for wanting a quick and fast prescription. But far more often than not, patients want opioids to play a role in a comprehensive treatment plan. They want painkillers so that their physical therapy exercises can be performed a little easier, or they believe opioids will help them live a more active lifestyle and combat their pain condition in other ways.

Painkillers can absolutely play an essential role in a pain care plan, but that doesn’t mean they should absolutely be prescribed for every patient. A totality of factors need to be analyzed in order to provide the best care for the patient, which is what all physicians should strive for. Doing right by the patient means taking the time to really understand their condition, their frustrations, their goals, their concerns and their opportunities. Sometimes that involves painkillers, sometimes it doesn’t. The sooner we realize that we need to come together to help find solutions for pain patients instead of condemning chronic pain sufferers and physicians, the better we all will be for it.